Oral health in patients with stroke: a meta-analysis of comparative studies

Dental Caries, Race and Incident Ischemic Stroke, Coronary Heart Disease, and Death

BACKGROUND

Dental caries is a highly prevalent disease worldwide. In the United States, untreated dental caries is present in >1 in 5 adults. The objective of this study was to determine the relationship between dental caries and incident ischemic stroke, coronary heart disease (CHD) events, and death.

METHODS

The dental cohort (n=6351) of the ARIC study (Atherosclerosis Risk in Communities) was followed for incident ischemic stroke, CHD event, and all-cause mortality. Of all the participants at visit 4 (n=11 656), those who were unable to go through dental examination, or with prevalent ischemic stroke and CHD events, were excluded. The full-mouth dental examination was conducted at visit 4 (1996-1998), assessing dental caries. The dose response of decayed, missing, and filled surfaces due to caries was assessed and related to the outcome. Outcomes were assessed through the end of 2019. Additionally, the effect of regular dental care utilization on dental caries was evaluated.

RESULTS

Participants with ≥1 dental caries had an increased risk of stroke (adjusted hazard ratio [HR], 1.40 [95% CI, 1.10-1.79]) and death (adjusted HR, 1.13 [95% CI, 1.01-1.26]) but not for CHD events (adjusted HR, 1.13 [95% CI, 0.93-1.37]). The association of dental caries and ischemic incident stroke was significantly higher in the African American population compared with the White subgroup (interaction term P=0.0001). Increasing decayed, missing, and filled surfaces were significantly associated with stroke (adjusted HR, 1.006 [95% CI, 1.001-1.011]) and death (adjusted HR, 1.003 [95% CI, 1.001-1.005]) but not CHD (adjusted HR, 1.002 [95% CI, 1.000-1.005]). Regular dental care utilization lowered (adjusted odds ratio, 0.19 [95% CI, 0.16-0.22]; P<0.001) the chance of caries.

CONCLUSIONS

Among the cohort, dental caries was independently associated with the risk of ischemic stroke and death, with the effect higher in African American participants. Regular dental care utilization was associated with a lower chance of caries, emphasizing its relevance in the prevention of these events.

Investigating oral health-related quality of life in patients with ischaemic stroke in China

OBJECTIVE

The objective of the study was to explore factors associated with oral health-related quality of life (OHRQoL) in patients with ischaemic stroke in China, guided by the theory of planned behaviour (TPB) and Andersen's oral health outcome model.

BACKGROUND

Recent studies have reported that the prevalence of stroke is increasing and that stroke patients are facing many oral health related problems. This study provided insights into the role of TPB in the OHRQoL among patients with ischaemic stroke.

MATERIALS AND METHODS

Three hundred eight patients with ischaemic stroke from the Department of Neurology of a third-grade class-A hospital in Xuzhou, China, were enrolled in this cross-sectional study between June and September 2020. They completed a questionnaire that included information on socio-demographic characteristics and health behaviours, the Montreal Cognitive Assessment Scale, the Modified Rankin Scale and the Chinese version of the Oral Health Impact Profile-14 scale (OHIP-14). Structural equation modelling (SEM) was used to examine the association among the selected variables based on the TPB and Andersen's oral health outcome model.

RESULTS

Among the participants (mean age 65.6), most (57.5%) were male. Their mean OHIP-14 score was 13.3 ± 7.6. Based on the SEM path diagram, behavioural attitude, subjective norms and perceived behavioural control of oral health were positively associated with intention; intention was associated with OHRQoL. The degree of disability was negatively associated with intention. Cognitive function was positively associated with OHRQoL.

CONCLUSION

The OHRQoL of hospitalised patients with ischaemic stroke in China is fair to poor and affected by their oral health behaviours. Improved oral health behavioural attitude, subjective norms and perceived behavioural control might help them form good intentions and improve their OHRQoL.

Influencing factors associated with oral health among older hospitalized patients with ischemic stroke: A cross-sectional survey

Objective

To investigate the oral health status of older patients with ischemic stroke and analyze the influencing factors, providing valuable insights for developing effective oral health management strategies tailored for this population.

Methods

A cross-sectional survey was conducted from January to June 2022, selecting 350 older patients with ischemic stroke from two tertiary hospitals in Chongqing. The Barthel Index (BI), Eating Assessment Tool (EAT-10), and Oral Health Assessment Tool (OHAT) were used to assess patients' self-care ability, swallowing function, and oral health status, respectively. A self-designed questionnaire was used to collect demographic information, disease-related information, and oral health behaviors of the patients. Binary logistic regression analysis was performed to analyze related influencing factors.

Results

A total of 346 older patients with ischemic stroke were included, with 199 males and 147 females. The median total score of OHAT was 5 (total score range 0-16). Dental decay (91.7%, 278/303) and poor oral hygiene (92.2%, 319/346) were the main oral health problems in this population. Binary logistic regression analysis showed that sex, hyperlipidemia, stroke severity, stroke events, oral health behaviors, and care dependency were influencing factors for the oral health of this population (P < 0.05).

Conclusion

The study revealed that healthcare professionals should strengthen the oral health assessment of older patients with ischemic stroke and implement individualized health education and management measures based on the characteristics of high-risk groups to promote their oral health.

Dental Caries a Risk Factor for Intracerebral Hemorrhage

INTRODUCTION

Streptococcus mutans is a known cause of dental caries that contains a collagen-binding protein, Cnm, and exhibits inhibition of platelet aggregation and matrix metalloproteinase-9 activation. This strain has been linked to aggravation of experimental intracerebral hemorrhage (ICH) and may be a risk factor for ICH. The purpose of this study was to test the association between dental caries and incident ICH.

METHODS

The presence of dental caries and periodontal disease was assessed in subjects from the Dental Atherosclerosis Risk in Communities (DARIC) study without prior stroke or ICH. This cohort was followed for incident ICH over a period of 10 years. Cox regression was used to compute crude and adjusted hazards ratio from the dental assessment.

RESULTS

Among 6,315 subjects, dental surface caries and/or root caries were recorded in 1,338 (27%) subjects. Of those, 7 (0.5%) had incident ICH over a period of 10 years following the visit 4 assessment. Of the remaining 4,977 subjects, 10 (0.2%) had incident ICH. Those with dental caries versus those without dental caries were slightly younger (mean age 62.0 ± 5.7 vs. 62.4 ± 5.6, p = 0.012), had a greater proportion of males (51 vs. 44%, p < 0.001), African Americans (44 vs. 10%, p < 0.001), and were hypertensive (42 vs. 31%, p < 0.001). The association between caries and ICH was significant (crude HR 2.69, 95% CI 1.02-7.06) and strengthened after adjustment for age, gender, race, education level, hypertension, and periodontal disease (adjusted HR 3.88, 95% CI 1.34-11.24).

CONCLUSION

Dental caries is a potential risk for incident ICH after caries detection. Future studies are needed to determine if treatment of dental caries can reduce the risk of ICH.

Relationships between stroke prevalence, health literacy, and oral health-related quality of life in middle-aged and older adults: a national survey study

BACKGROUND

Stroke may cause debilitating neurological deficiencies that result in motor, sensory, and cognitive deficits and poorer psychosocial functioning. Prior studies have provided some initial evidence for the significant roles of health literacy and poor oral health for old people. However, few studies have focused on the health literacy of individuals who had a stroke; therefore, the relationships between the health literacy and oral health-related quality of life (OHRQoL) among middle-aged and older adults who had a stroke are unknown. We aimed to assess the relationships between stroke prevalence, health literacy status, and OHRQoL in middle-aged and older adults.

METHODS

We retrieved the data from The Taiwan Longitudinal Study on Aging, a population-based survey. For each eligible subject, we gathered data in 2015 on age, sex, level of education, marital status, health literacy, the activity daily living (ADL), stroke history and OHRQoL. We evaluated the respondents' health literacy by using a nine-item health literacy scale and categorized their health literacy level as low, medium, or high. OHRQoL was identified based on the Taiwan version of the Oral Health Impact Profile (OHIP-7T).

RESULTS

The final study contained 7702 community-based dwelling elderly people (3630 male and 4072 female) were analysis in our study. Stroke history was reported in 4.3% of participants, 25.3% reported low health literacy, and 41.9% had at least one ADL disability. Furthermore, 11.3% of participants had depression, 8.3% had cognitive impairment, and 3.4% had poor OHRQoL. Age, health literacy, ADL disability, stroke history, and depression status were significantly associated with poor OHRQoL after sex and marital status was adjusted. Medium (odds ratio [OR] = 1.784, 95% confidence interval [CI] = 1.177, 2.702) to low health literacy (OR = 2.496, 95% CI = 1.628, 3.828) was significantly associated with poor OHRQoL.

CONCLUSIONS

Base our study results, people with stroke history had poor OHRQoL. Lower health literacy and ADL disability were associated with worse QHRQoL. Further studies are necessary to define practical strategies for reducing the risk of stroke and oral health with constantly lower health literacy, thereby improving the quality of life and providing health care of older people.

Factors that influence oral hygiene care with hospitalised stroke patients: a mixed methods study

PURPOSE

Survivors of stroke experience poor oral health during and following hospitalisation. Health professionals consistently report that oral hygiene is complex. Interventions aiming to improve the delivery of oral hygiene care by health professionals rarely use a theoretically driven approach. This study reports the first phase in an intervention development and uses the action, actor, context, target, time (AACTT) framework and theoretical domains framework (TDF) to understand who needs to do what differently in the delivery of oral hygiene care with hospitalised stroke survivors.

METHOD

Mixed methods including analysis of oral health policies and clinical guidelines using the AACTT framework, focus group discussions using the TDF and audit of 60 medical records.

RESULTS

Policies and guidelines lack specificity regarding what oral hygiene care is and who should be responsible. Health professionals have low beliefs in their capabilities and experience numerous contextual barriers. More than 40% of patients had no documented evidence of oral hygiene care.

CONCLUSION

This study used a theoretically driven approach to identify barriers and enablers to health professional delivery of oral hygiene care with stroke survivors. Interventions aiming to improve clinical practice should target beliefs about capabilities, improved access to resources and detailed oral hygiene clinical guidelines.Implications for rehabilitationSurvivors of stroke experience poor oral health which can contribute to further strokes, cardiovascular disease and mortality.Health care professionals report difficulties in delivering oral hygiene care to hospitalised stroke survivors and clinical guidelines lack detail regarding oral health assessments, interventions and training.Interventions aiming to improve the delivery of oral hygiene care should target health professional beliefs about their capabilities using strategies such as behavioural practice.Resources specific to oral hygiene care for more complex patients, including suctioning toothbrushes, should be readily accessible for health professional use.Clinical guidelines and policies on oral hygiene care should include detail about training content, assessments tools and how to adapt information for patients with complex impairments.

Oral health status and its associated factors among post-stroke inpatients: a cross-sectional study in Hungary

Background

Post-stroke inpatients are at risk of poor oral health for a number of reasons. The aim of this study was to assess the oral health status of post-stroke patients and also to explore the factors that may influence it.

Methods

This cross-sectional study was organised at National Institute for Medical Rehabilitation in Hungary. Altogether 410 post-stroke patients were enrolled in the survey. Personal medical history and functional assessment was obtained from the final medical reports of the patients. The clinical examination and data collection were conducted according to the World Health Organization (2013) criteria. Socio-demographic background and behaviours related to oral health were assessed using a questionnaire. The dental status was explained by the number of Decayed, Missing and Filled Teeth (DMFT). The association of socio-demographic factors, stroke and functional assessment with oral health status and behaviour was evaluated. Chi-square test, Fisher’s exact test, Welch test, Mann–Whitney U test, Kruskal–Wallis test, ANOVA model and correlation analysis were used to analyse our data. The level of significance was set at p < 0.05.

Results

Mean age of stroke patients was 59.21(Standard Deviation [SD] 14.74) years. Mean DMFT score was 20.13 (8.08), including 3.28 (4.24) decayed teeth, 15.02 (10.29) missing teeth and 1.83 (2.94) filled teeth score. Factors that influenced the oral health status were gender, age, occupational status, level of education, type and risk factors for stroke. Significant correlation was found between the Functional Independence Measure and oral health-related behaviours with patients brushing their teeth once a month showing the lowest value.

Conclusion

According to the results, low socio-demographic and economic status, low level of education and the Functional Independence Measure score, unemployment, the combination of risk factors for stroke and residual dysfunctions are associated with poor oral health status. The data indicate that a series of changes are needed, for special attention and care in oral health for patients who have had a stroke. Based on the findings of this research, a new model of prevention and care can be developed, with an interdisciplinary collaboration, to promote the quality of life of these individuals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02259-2.

Oral health in patients with dementia: A meta-analysis of comparative and observational studies

OBJECTIVE

Poor oral health is common in dementia, but findings of epidemiological studies have been inconsistent. This meta-analysis examined oral health in patients with dementia diagnosed according to standardized diagnostic criteria.

METHODS

Six international databases (PubMed, EMBASE, PsycINFO, Medline, Cochrane Library, and Web of Science) were searched from their commencement date until 8 November 2018. Oral health was measured by the Remaining Teeth (RT) and Decayed, Missing, and Filled Teeth (DMFT) Index. The mean differences (MD) and 95% confidence intervals (CI) of DMFT Index total and component scores were calculated using a random-effect model.

RESULTS

Twenty-four studies were included for analyses. The pooled DMFT Index was 23.48 (95% CI: 22.34, 24.62), while the pooled score for each component was 2.38 (95% CI: 1.56, 3.20) in decayed teeth (DT), 18.39 (95% CI: 15.92, 20.87) in missing teeth (MT), 2.29 (95% CI: 0.62, 3.95) in filled teeth (FT), and 11.59 (95% CI: 9.14, 14.05) in RT. Compared to controls, people with dementia had significantly a higher DMFT Index total score (MD = 3.80, 95% CI: 2.21, 5.39, p < 0.00,001), and significantly lower number of RT (MD = -3.15, 95% CI: -4.23, -2.06, p < 0.00,001). Subgroup analyses revealed that higher DMFT Index score was significantly associated with year of survey (>2010), study design (case-control study), percentage of females (≤54.3), and the Mini Mental State Examination score (≤18.2). Higher MT score was significantly associated with study design (cross-sectional study), and lower FT score was significantly associated with year of survey (>2010).

CONCLUSIONS

Oral health was significantly poorer in people with dementia compared with controls. Regular screening and effective treatment should be implemented for this population.

Patient perceptions of oral health care following stroke: a qualitative study

BACKGROUND

Stroke is a serious cerebrovascular disease and is one of the world's leading causes of disability. Maintaining good oral health is a challenge among those hospitalised after stroke. A multidisciplinary approach to oral care involving non-dental professionals can be beneficial in improving oral health outcomes for patients. The aim of this study was to understand the perceptions of stroke survivors regarding oral healthcare across acute and rehabilitation settings.

METHODS

A descriptive qualitative approach was used. Face-to-face semi-structured interviews were conducted. A framework analysis was employed to analyse the data. Patients who had recently experienced a stroke were purposively recruited across both acute and rehabilitation settings, at two metropolitan hospitals in Sydney, Australia. In total, 11 patients were interviewed.

RESULTS

Although participants recognised the importance of oral health, few understood the link between oral and general health. Regular oral hygiene practices varied since having stroke, with a few receiving oral care assistance from nurses. Time, cost and lack of information were some barriers to accessing dental services, while supportive measures such as coordination of oral care, financial subsidy and nurse assistance were strategies proposed to support oral care practices amongst stroke survivors.

CONCLUSIONS

There is scope to improve current models of oral care in stroke. While stroke survivors understand the importance of oral care, an integrated oral health model with a multidisciplinary approach could improve health outcomes.

Is an Oral Health Status a Predictor of Functional Improvement in Ischemic Stroke Patients Undergoing Comprehensive Rehabilitation Treatment?

The study's aim was a clinical observation concerning the influence of oral health on functional status in stroke patients undergoing neurorehabilitation. This pilot cross-sectional clinical study was performed in 60 subacute phase stroke patients during 12 weeks of treatment. The program was patient-specific and consisted of neurodevelopmental treatment by a comprehensive rehabilitation team. The functional assessment was performed using the Barthel index (BI), Berg balance scale (BBS), functional independence measure (FIM), and Addenbrooke's cognitive examination III (ACE III) scales. Oral health was assessed according to World Health Organization (WHO) criteria, and it was presented using DMFT, DMFS, gingival index (GI), and plaque index (PlI). Significant improvement in many functional scales was noticed. However, important differences in most dental parameters without relevant changes in GI and PlI after the study were not observed. Reverse interdependence (p < 0.05) was shown between physical functioning (BI, FIM, or BBS) with GI and PlI results, and most dental parameters correlated with ACE III. Using multivariate regression analysis, we showed that ACE III and BI are predictive variables for DMFT, just as FIM is for DS (p < 0.05). The present research revealed that poor oral health status in patients after stroke might be associated with inpatient rehabilitation results.